Workers Compensation Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

* Last Name

* First Name

Business Name

Street Address

City

State

Zip Code

Phone Number

Alternate Telephone

Fax Number

* Email Address

Underwriting Information

What is the nature of your business?

Is the business a corporation, partnership, or sole proprietorship?

Corporation

Partnership

Sole Proprietorship

Number of owners

Number of Employees

Payroll of Owners

Payroll of Employees

Total annual gross receipts

Business License Number

License Type

Years of experience

Years operated under current name

Other business names

Yes

No

Is this business open 24 hours a day?

Yes

No

Any deep frying (food)?

Yes

No

Is there any manufacturing, mixing, re-labeling or repackaging of products?

Yes

No

Is there filling of propane tanks?

Yes

No

Please describe the nature of your business and ANY unusual exposures:

Payroll Detail Information

Employee Group 1

Class / Code

Payroll Rate

Annual Payroll

Employee Group 2

Class / Code

Payroll Rate

Annual Payroll

Employee Group 3

Class / Code

Payroll Rate

Annual Payroll

Employee Group 4

Class / Code

Payroll Rate

Annual Payroll

Employee Group 5

Class / Code

Payroll Rate

Annual Payroll

Claims Information

Were there any losses or claims in the last 5 years?

Yes

No

If yes, what is the date, amount paid and description of each loss or claim?

Coverage Information

Current Insurance Company

How much are you paying now?

What is the liability limit requested?

Questions or Comments

Best Time To Contact You

Please let us know the best time to call and discuss your quote.

Morning

Afternoon

Evening

Anytime

Or Specify Other:

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